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n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FO1rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,,^'S x/11/v <br /> M ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> E (Complete In Triplicate) <br /> Application is hereby made to the" San Joaquin Local Health District for a permit to construct <br /> and./or install the work herein described. This application is.made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of 'the San Joaquin Local Health District, <br /> ,JOB ADDRESS/LOCATION „2 ' <br /> CENSUS TRACT <br /> Owner's Name .' <br /> ` Phoae <br /> Address a2 <br /> City <br /> C <br /> x <br /> Contractor's Name License'# �GO , Phone -,�- <br /> TYPE OF WORK (Check): NEW WELL _0 DEEPEN/? .RECONDITION /? MP DESTRUCTION . <br /> f PUMP INSTALLATION / / PUMP REPAIR <br /> I Other /% / / PUREPLACEMENT— g <br /> DISTANCE TO NEAREST: SEPTIC TANKW <br /> 7c,� SEWER LINES PIT PRIVY ; w C7 <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE - PRIVATE DOMESTIC WELL 'PUBLIC DOMESTIC WELL <br /> INTENDED U TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable,Tool Dia. of well Excavation <br /> Domestic/private Drilled_­ -` ' _ Dia. of'Well Casing <br /> - <br /> Domestic/public _ Driven Gauge_of Casing t <br /> Irrigation 12 <br /> Gravel Pack Depth of Grout Seal, <br /> F ' Cathodic Protection 15 <br /> - <br /> - _'Rotary Type of" Grout .;. <br /> Disposal. Other Other Information <br /> Geophysical <br /> Surface Seal Iinstalled BY: <br /> PUMP INSTALLATION: <br /> Contractor LIF <br /> Type of_, Pump ry` t \, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR. State? ork-Done a <br /> ES;TRUCTION OF WELL: Well Diameter "` e` - <br /> Describe Materia-rand Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the. well in.use.. The above <br /> information -is-true-to--the.best--of.-my-knowledge--and belief•: - I;WILL--CALL-FOR--i"'GROUT INSPECTION <br /> PRIOR TO GROUT NG AND FIN ECTION. <br /> 5TGNED t � { TITLE ( <br /> (DRAW Pi;OT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 1 GR UT INSPECTION ASIIFINAL INSPECTION <br /> INSPECTION BY DAT LT 737 INSPECTION B_Y .. DATE <br /> f <br /> t E H 1426 Rev. 1=14 <br /> •i_7i '2u <br />